肾移植术后髂内动脉自体移植治疗感染性髂外动脉出血(附一例报告及文献复习)

目的 探讨肾移植术后感染性髂外动脉吻合口出血的处理。方法 报告1例髂内动脉自体移植治疗感染性髂外动脉吻合口大出血病例，结合文献复习讨论。患者，男，25岁。肾移植术后第22、24、38天3次出现感染性移植。肾动脉髂外动脉吻合口大出血，出血量分别达800、2500、3800ml。经输血、及时手术探查，两次吻合口缝合修补效果不佳，第3次手术切除移植肾，并将感染病变严重的髂外动脉段切除，髂外动脉缺损长约2cm，以3cm长的髂内动脉段移植修复。结果 修复后髂外动脉血流通畅，患侧下肢血供良好，患者恢复血液透析，等待再次移植。结论 感染性移植肾动脉髂外动脉吻合口出血为肾移植术后严重并发症，单纯修补常难以奏效，髂内动脉自体移植修补缺损合理可行，操作简易，效果较好。     

肾移植术中采用供肾动脉与髂外动脉吻合的体会

对２７例髂内动脉有严重动脉粥样硬化的肾移植受者实施供肾动脉与受者髂外动脉端侧吻合术，术后除有３例患者因环孢素用量过大使移植肾功能恢复略延迟外，其它２４例患者均于术后４天内肾功能恢复正常，且无一例外科并发症。认为该术式可作为髂内动脉情况异常的一种弥补方法，但不宜作为常规术式。     

供肾动脉与髂外动脉端侧吻合行肾移植术的临床研究

本文通过对供肾动脉与髂内动脉端端吻合（ＥＥＡ）及与髂外动脉端侧吻合（ＥＳＡ）二种方法的比较，结果显示：ＥＳＡ组非常显著地缩短了手术时间（Ｐ〈０．００１）；ＥＥＡ组动脉吻合口狭窄发生率为７％，显著高于ＥＳＡ组；二组正常功能移植肾血流无显著性差异；ＥＳＡ组多支动脉供肾利用率为９４．４％，显著高于ＥＥＡ组。同时认为ＥＳＡ减少体外多支动脉供肾血管重建手术，缩短冷缺血时间，减少供肾损伤。     

髂内动脉移位重建髂外动脉一例

髂内动脉移位重建髂外动脉一例贺青卿徐良王晨龙张小化刘国勤单礼成患者男，２０岁。因左下腹被铁钝器撞击伤，下肢功能障碍８小时，于１９９７年８月２９日急诊入院。检查：左髂窝有一直径５ｃｍ的圆形皮肤挫伤，皮下淤血，左下腹膜刺激征阳性，直肠指检无异...     

供肾动脉与受者髂外动脉吻合的肾移植618例

限于受者的血管情况,我们采取供肾动脉与受者的髂外动脉吻合,共完成肾移植618例,现报告如下。618例中,男性542例,女性76例,年龄13～73岁,平均35.3岁,病程平均为1.7年。其原发病,560例为慢性肾小球肾炎,26例为糖尿病肾病,17例为多囊肾,10例为药物性肾病,2例为遗传性肾炎,2例为狼     

选择髂内或髂外动脉吻合对移植肾的影响

目的 探讨肾移植动脉重建选择髂外或髂内动脉时移植肾血流参数、肾脏功能和血管并发症的差异。方法 135例初次肾移植患者随机分为2组，2组患者平均年龄、HLA错配数目、淋巴细胞毒试验、冷／热缺血时间差异均无统计学意义（P〉0．05），术后免疫抑制剂应用方案相同。应用髂外动脉端侧吻合66例，髂内动脉端端吻合69例。随访3个月，比较2组患者肾脏功能、彩色多普勒肾脏血流参数和血管并发症发生率。结果 髂内动脉、髂外动脉组2组患者术后3个月时肾功能监测指标（Cr：118．41 vs123．68μmol／L），移植肾主肾动脉、段动脉、大叶间动脉血流及阻力指数差异无统计学意义（P〉0．05）。结论 肾移植动脉重建选择髂内外动脉对移植肾功能及血液流变学无明显影响，动脉选择应根据患者具体情况决定。     

腹膜后肉瘤联合大段髂外动脉切除后与髂内动脉吻合重建可行性分析

目的 探讨腹膜后肉瘤联合大段髂外动脉切除后与同侧或对侧髂内动脉进行吻合的可行性与安全性。方法 回顾性分析2017年1月至2019年9月北京大学肿瘤医院软组织与腹膜后肿瘤中心收治的5例腹膜后肉瘤联合大段（5~8 cm）髂外动脉切除病例的临床资料,均未使用人工血管,而采用与同侧或对侧髂内动脉进行吻合重建。 结果 5例病人均完整切除肿瘤,手术时间为380～540 min,术中出血600～4000 mL。术后病理学检查示,平滑肌肉瘤2例,去分化脂肪肉瘤1例,多形性脂肪肉瘤1例,多形性未分化肉瘤1例。肿瘤最大径为15～23 cm,均为R0切除。无腹腔感染、腹腔出血、消化道或泌尿道瘘等术后并发症。术后1周增强CT检查示动脉吻合通畅,术后住院时间为10～20 d,无围手术期死亡。随访33（12~45）个月,重建动脉均保持通畅,无复发和死亡病例。结论 腹膜后肉瘤联合大段髂外动脉切除后可选择与同侧或对侧髂内动脉进行吻合重建,安全可行。     

急诊动脉栓塞术在产后出血中的应用

目的　评价急诊经导管动脉栓塞术 (TAE)治疗难治性产后出血的疗效及安全性。方法　 18例难治性产后出血选择性插管至双侧髂内动脉或子宫动脉 ,行数字减影血管造影 (DSA)明确出血原因、部位后 ,以直径 1～ 3mm明胶海绵颗粒栓塞。结果　插管成功率 10 0 % ,手术时间 3 0～ 60min ,平均 ( 4 5 .2± 4.8)min ,术后止血总有效率 10 0 %。术后随访 3～ 40个月 ,均无严重并发症发生 ,所有患者宫体按期复旧 ,转经后月经正常。结论　TAE创伤小 ,疗效快速肯定 ,术后短期及长期随访无严重并发症 ,对危及生命的产后出血是一种有效的治疗措施     

超选择性髂内动脉分支栓塞治疗前列腺癌术后出血3例

目的 评价超选择性髂内动脉分支栓塞治疗前列腺癌术后出血的疗效.方法 应用大小不等的弹簧钢圈或PVA颗粒,对3例前列腺癌根治术后盆腔出血患者进行超选择性髂内动脉分支栓塞术.结果 栓塞后出血均停止,血红蛋白水平保持平稳,持续随访无再发出血.结论 超选择性髂内动脉分支栓塞术是一种有效治疗前列腺癌根治术后盆腔出血的方法.     

肾移植供肾动脉与髂外动脉端侧吻合术115例临床体会

我院从 1997年 3月～ 2 0 0 0年 2月期间 ,对 115例尿毒症患者行同种异体肾移植手术 ,采用供肾动脉与髂外动脉端侧吻合替代供肾动脉与髂内动脉端端吻合术 ,并取得了较好的临床效果 ,现报告如下。资料与方法1　一般资料　本组 115例 ,女 36例 ,男 79例 ;年龄在 18岁～ 71岁 ,其中 55岁以上有 31例 ;原发病慢性肾小球肾炎 10 4例 ,多囊肾 5例 ,痛风 6例。供肾灌洗后用ＨＣＡ液保存 ,热缺血时间 3～ 10ｍｉｎ ,冷缺血时间 180～ 4 80ｍｉｎ ,淋巴毒试验小于 10 % ,我们手术切口习惯采用右下腹弧形切口 110例 ,左下腹弧形切口 5例 (均为第二次移…     

Use of internal iliac artery as a side-to-end anastomosis in renal transplantation

The internal iliac artery is less commonly used in renal transplantation in comparison to the external iliac artery due to its size and the risk of compromising distal vascular supply to the pelvis. We report a cadaveric renal transplant in which we performed a side-to-end anastomosis using the internal iliac artery. This technique can provide adequate perfusion to the transplant kidney without the associated risks and complications in the patient whose internal iliac artery is of a good diameter and quality.     

Massive hematuria after cystoscopy in a patient with an internal iliac artery aneurysm.

An unusual case is reported here of a patient with internal iliac artery aneurysm who developed massive hematuria after cystoscopic examination. A 75-year-old man presented with asymptomatic gross hematuria. Cystoscopic examination revealed that the bladder neck was congested and that the right-side wall was being pressed on by an extrinsic mass. Computed tomography showed a right internal iliac artery aneurysm and tortuous perivesical vessels. Three days after the cystoscopic examination the patient suffered massive hematuria. Hemorrhage due to an arteriovesical or arterio-ureteral fistula secondary to rupture of the internal iliac artery aneurysm was suspected, and an emergency operation was performed. At operation the aneurysm had not ruptured but overswelling perivesical vessels were found to have developed, and these fed a high blood flow to the bladder neck. In the present case cystoscopic examination injured the mucosa and led to massive hemorrhage from the bladder neck.     

小颗粒明胶海绵栓塞犬髂内动脉及骶正中动脉后并发症的研究

目的用小颗粒明胶海绵对犬髂内动脉及骶正中动脉行不同组合、不同级别栓塞,观察栓塞后并发症发生情况,为临床安全应用明胶海绵栓塞骶区血管提供参考依据。方法普通级成年健康犬16只,雄性14只,雌性2只,体重10～13 kg;随机分为5组。于数字减影血管造影监视下采用直径为50～150μm的明胶海绵颗粒,A组(3只)栓塞至双侧髂内动脉及骶正中动脉主干,B组(3只)栓塞至双侧髂内动脉及骶正中动脉一级分支,C组(3只)栓塞至双侧髂内动脉主干,D组(4只)栓塞至单侧髂内动脉及骶正中动脉主干,E组(3只)栓塞至单侧髂内动脉主干。栓塞前观察实验犬腹主动脉、双侧髂外动脉、髂内动脉及骶正中动脉的解剖关系。栓塞后观察实验犬存活情况,并于栓塞后3 d行犬直肠、膀胱、臀部肌肉及坐骨神经大体和组织学观察。结果犬的髂外动脉及髂内动脉无髂总动脉,双侧髂外动脉直接起始于腹主动脉,骶正中动脉起始有变异。血管栓塞后2 d内共7只实验犬死亡,其中A组3只,C组3只,D组1只;其余实验犬均存活至实验完成。A、C、D组死亡实验犬直肠发黑、坏死,膀胱呈片状发暗伴灶状充血水肿,膀胱内尿量中位数为270.6 mL。B、D、E组存活实验犬直肠无明显异常,膀胱仅轻度片状充血水肿,膀胱内尿量中位数分别为137.0、220.5、28.0 mL。A、C、D组死亡实验犬直肠、膀胱细胞崩解,伴大量炎性细胞浸润及上皮细胞脱落;B、D、E组存活实验犬栓塞后3 d膀胱、直肠轻度炎性细胞浸润,栓塞血管主要集中于直径为100～200μm的小动脉。各组坐骨神经与臀部肌肉除有轻度水肿外未见明显异常。结论 采用直径为50～150μm的小颗粒明胶海绵栓塞犬髂内动脉及骶正中动脉时,应注意栓塞近端血管至主干时至少需保留单侧髂内动脉,双侧髂内动脉与骶正中动脉同时栓塞时被栓塞血管近端不能超过其一级分支,否则可造成盆腔脏器坏死、穿孔等严重并发症。     

Treatment of internal iliac artery aneurysms: single‐centre experience

Background: The aim of the present study was to analyse the short‐term results of treatment of internal iliac artery aneurysms (IIAA). Methods: In a prospective single‐centre cohort study all patients with IIAA (symptomatic or maximal diameter ≥30 mm) were evaluated for endovascular repair, which included coil embolization of the run‐off vessels and coverage of the orifice of the IIAA with a stent graft. Open repair was performed with aneurysm excision or aneurysmorrhaphy. Outcome criteria were technical and clinical success and complications of treatment. Results: In a period of 40 months 11 patients underwent operation for 12 IIAA. Nine aneurysms were repaired endovascularly and three with open repair. Coil embolization was routinely performed in all cases. At a median follow up of 18 months, technical and clinical success was 100%. Major complications included two early limb thromboses, a contrast‐agent‐induced nephropathy, and an intraoperative ureteric injury. Conclusion: Despite the limited number of patients, the present series, with good short‐term results, further supports the trend towards endovascular repair of suitable IIAA.     

右侧髂窝移植肾失功合并同侧髂总动脉夹层动脉瘤及髂外静脉狭窄1例

正患者女,45岁,因慢性肾功能不全接受右侧髂窝肾移植术,术后4h血压进行性下降,给予多种大剂量血管活性药物后血压波动于30～50/20～40mmHg,心率130～150次/分,失血性休克,伴右下肢肿胀逐渐加重。急诊床旁超声:右侧髂窝移植肾大小正常,各级动脉血流树稀疏,可见三级动脉,频谱呈针状高速高阻型(图1A),移植肾静脉内未见明确血流信号(图1B),肾周血肿;右股动脉纤细,远端流速减低;右下肢深、浅静脉内径增宽,其内未见血流信号,未见明确血栓。     

Outcome of hepatic artery reconstruction in liver transplantation with an iliac arterial interposition graft

BACKGROUND: In case of anomal hepatic arterial inflow, it can be necessary to perform revascularization of the liver allograft by iliac arterial interposition graft. METHODS: We analyzed retrospectively 613 liver transplants in a 16-yr period. The hepatic artery (HA) graft group (n = 101) consisted of patients with arterial inflow based on recipient infrarenal aorta using donor iliac artery graft tunneled through the transverse mesocolon. The control group (n = 512) consisted of patients who underwent liver transplantation with routine HA reconstruction. RESULTS: Both groups are homogeneous and comparable. In case of retransplantation, arterial conduit with iliac graft was adopted more frequently instead of conventional arterial anastomosis (24.8% vs. 9%, p < 0.0001). The 1-, 3- and 5-yr overall survival was 85.41, 79.42, 76.57% in the control group and 76.21, 73.43, 73.43% in the HA graft group, respectively (p = ns). The 1-, 3- and 5-yr graft survival was better in the control group (81.51, 73.66, 69.22% vs. 71.17, 62.50, 53.42%) (p = 0.01). In case of retransplantation, the 1-, 3- and 5-yr overall (57.81, 53.95, 41.96% vs. 60, 51.95, 49.85%) and graft survival (57.52, 53.68, 41.75% vs. 56, 50.4, 40.3%) was similar in control and HA graft group, respectively (p = ns). Hepatic artery thrombosis (HAT) rate is 21.8% vs. 8.6% (p < 0.0001) in HA graft group and control group, respectively. The only factor independently predictive of early HAT resulted arterial conduit (p = 0.001, OR = 3.13, 95% CI: 1.57-6.21). Retransplant procedure, donor age and arterial iliac conduit were found to be a significant risk factors for late HAT, at univariate analysis. At multivariate analysis, donor age >50 yr old resulted the only factor independently associated with late HAT (p < 0.0001, OR = 1.05, 95% CI: 1.02-1.07). CONCLUSION: Iliac arterial interpositional graft is an alternative solution for arterial revascularization of liver allograft in case of retransplantation when the use of HA is not possible. In case of primary transplantation, is better not to perform arterial conduit if it is possible, for poor graft survival and high incidence of early HAT, especially in case of liver donor aged over 50 yr.     

髂内动脉钙化对肾移植受者移植物功能延迟恢复和近期预后的影响

目的  分析髂内动脉钙化与肾移植受者移植物功能延迟恢复（DGF）及近期预后的相关性。方法  回顾性分析222例肾移植受者的临床资料。依据肾功能恢复情况分为DGF组（50例）和移植物功能正常恢复（IGF）组（172例）,根据是否合并髂内动脉重度钙化将DGF组和IGF组分为DGF高危组（22例）、DGF低危组（28例）、IGF高危组（41例）以及IGF低危组（131例）。比较两组供受者临床资料,总结肾移植术后DGF及髂内动脉钙化发生情况,分析肾移植术后发生DGF的危险因素、髂内动脉钙化与临床指标的相关性以及DGF合并髂内动脉重度钙化受者近期预后。结果  本研究中DGF发生率为22.5%（50/222）。肾移植受者中28.4%（63/222）合并髂内动脉重度钙化,DGF组中44%（22/50）合并髂内动脉重度钙化,高于IGF组中的23.8%（41/172）（P < 0.05）。单因素分析结果显示供者终末血清肌酐（Scr）高、男性供者,受者甘油三酯水平高和髂内动脉重度钙化是肾移植术后发生DGF的危险因素（均为P < 0.05）。多因素logistic回归分析显示供者Scr≥143 μmol/L及受者髂内动脉重度钙化是肾移植术后发生DGF的独立危险因素（均为P < 0.05）。相关性分析结果显示髂内动脉钙化与受者年龄和肾动脉吻合方式均呈弱相关（均为P < 0.05）。DGF组受者术后1个月的Scr高于IGF组,估算肾小球滤过率（eGFR）低于IGF组（均为P < 0.05）;DGF高危组受者术后12个月的eGFR低于DGF低危组、IGF高危组以及IGF低危组（均为P < 0.05）。结论  髂内动脉钙化不仅是影响移植肾功能恢复的危险因素,也对移植肾功能的近期预后造成不良影响。